A realist evaluation of the development, implementation and outcomes of the first public ART Centre in Morocco

In Morocco, access to assisted reproductive technology (ART) in public hospitals has been limited, and many couples cannot afford private sector services. In this context, a public ART centre was established in 2013 at the Maternity and Reproductive Health Hospital in Rabat. This study aimed to evaluate this first public ART centre to understand how the intervention worked, for whom, and under what circumstances, and to inform replication in Morocco and other low- and middle-income countries (LMICs). A realist evaluation was conducted, combining qualitative in-depth interviews with couples, healthcare providers, and policymakers, and a retrospective analysis of clinical outcomes among all couples receiving ART services at the centre. Data were analysed to develop context-mechanism-outcome configurations explaining how and why the intervention worked. Contextual factors such as the high cost of IVF, the social value of childbearing, and stigma associated with infertility influenced service utilization. Key mechanisms included advanced planning, workforce training, standardized procedures, patient-centred care, and strong leadership and governance. Outcomes included the establishment of a regulatory framework for ART, perceived improvement in financial affordability, and perceived reduction in infertility-related stigma. Knowledge transfer contributed to the development of additional centres in various regions of the country. Between October 2013 and December 2022, 2,495 couples received fertility services. Clinical pregnancy rates were 23.8% for IVF and 21% for frozen embryo transfer, with corresponding live birth rates of 16.6% and 14.3%. The creation of the first public ART centre represents a milestone in the management of infertility in the Moroccan public health system. It has improved access and perceived affordability to ART, although some clinical outcomes require further improvement. These findings provide useful lessons to inform the development of public ART services in other LMICs.